Provider Demographics
NPI:1508639964
Name:PENA, IMELDA (CPO)
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12315 JUDSON RD STE 206
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3264
Mailing Address - Country:US
Mailing Address - Phone:210-657-8100
Mailing Address - Fax:210-657-8105
Practice Address - Street 1:12315 JUDSON RD STE 206
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3264
Practice Address - Country:US
Practice Address - Phone:210-657-8100
Practice Address - Fax:210-657-8105
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1312222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist